AMP CAMP 2018 CAMPER REGISTRATION FORM WHEN: Friday 9th - Sunday 11th March 2018*
* Monday 12th March Optional Extra Day (extra cost applies)
WHERE: Teen Ranch (352 Cobbity Road, Cobbity NSW 2570)

Amp Camp is Australia’s only camp for youth (12-21 years) living with limb loss or limb difference. Proudly hosted by Amputees NSW, Amp Camp is organised and run by volunteer members and associates of Amputees NSW.
For more information, visit us online www.amputeesnsw.org.au or Free Call 1800 810 969.

CAMP DIRECTOR:
RUSSELL HODGE
E: russell@cornerstone.edu.au
M: 0412 57 37 88

Email address *
Campers Application/Registration Form
This form is to be completed by Parents/Guardians. In submitting this form you are declaring your acceptance of the conditions outlined below and contained within the form. If you wish to apply for a Leader Role please complete the Amp Camp Leader Application Form: https://goo.gl/forms/pHK2Wt7T16Rx519N2

Risk Warning: I/we understand that recreational activities organised by Teen Ranch Limited may include horse riding, canoeing, abseiling, and low and high ropes courses. These and other recreational activities arranged from time to time are of their nature inherently dangerous. I understand that Teen Ranch is accredited by the Australian Camping Association, which means its camps comply with Australian industry best practice contained in the standards set by that organisation.

In submitting this application form I/we acknowledge on behalf of the Camper attending Teen Ranch for the camp that the paragraph above constitutes a risk warning under the terms of the Civil Liability Act 2002 (New South Wales), and I/we hereby release Teen Ranch and the Amputee Association of Sydney, their officers, employees and volunteers from liability to the extent permitted under the terms of that Act.

Medical Assistance: In the event of injury or illness of any camper, I/we acknowledge the Camp Director will endeavour to contact me/us on the telephone number/s provided in this form, but in the event of emergency, authorise the Camp Director to obtain all necessary medical assistance, including ambulance transport and hospital accommodation, and I/we agree to pay for all related fees and expenses.

For queries about Amp Camp contact Camp Director: Russell Hodge 0412 573 788

Camper Details
First Name & Surname: *
Your answer
Preferred Name at Camp
Your answer
Sex *
Required
Date of Birth *
MM
/
DD
/
YYYY
Postal Address: *
Please provide full Postal address including State & Post Code
Your answer
Parent/Guardian Details
Names: *
Your answer
Mobile Phone Contact (or best contact number): *
Your answer
Email: *
Your answer
Health & Emergency
Emergency Contact Person *
(if parent/guardian cannot be contacted)
Your answer
Emergency Contact Number *
(if parent/guardian cannot be contacted)
Your answer
Relationship to Camper *
Your answer
Camper Medicare Number Including Card Ref No *
Your answer
Medicare Expiry Date *
MM
/
DD
/
YYYY
Limb Difference / Loss / Amputation and related special needs *
Please describe in detail eg Right Above Knee Amputee
Your answer
Medication requirements? Allergies? *
Required
If Yes: Outline medication, dosage, purpose & times. Please detail any allergies and required treatment.
Your answer
Behavioural Problems *
Required
If Yes please specify
Your answer
Special Dietary Requirements *
Required
If Yes please specify
Your answer
Bed Wetting and or Unusual Sleep Behaviours? *
Required
If Yes please specify
Your answer
Parental/Guardian Consent for administration of Non-scheduled Medications if required *
Required
Other Information
Is there anyone who is legally restricted from seeing this camper? *
Required
If Yes please provide details.
Your answer
Will the camper require a Carer to attend the camp? Where camper is restricted to a wheelchair it recommended a carer accompany them. *
Required
If Yes please provide Carer's name, contact details and relationship to camper.
Your answer
Photographs & Video Taken at Amp Camp *
Please Note: Photographs may be used, in an unidentified form, as part of future Amp Camp and or Teen Ranch promotional material. In 2018 a film crew from Small World Stories will be taking footage and conducting interviews in preparation for an Amp Camp documentary film. www.smallworldstories.org
Required
A complimentary camp T-Shirt may be provided to campers. Please select the preferred shirt size. Please Note: We have had sizing issues in the past. To avoid disappointment - Bigger is usually better. *
Required
Camp Payment
Amp Camp is mostly funded through grant funding submissions applied for by the Amputee Association. Successful grant submissions are proving more challenging each year. Each camper is required to pay a minimum camp contribution of $55.00. If your child has been to camp two or more times please consider helping to raise funds to cover their (or anothers) full camp cost. On average it costs $500.00 per camper to attend Amp camp.

** Due popular request we are extending Amp Camp for an "optional" extra day. The cost for this will be $40.00. This covers an extra night accommodation (& Breaky) at Teen Ranch and transport to our Monday Activity. If participating in this please pay $95.00.

Camp Options *
Required
Camp Contribution *
Please select your preferred payment option and forward the Amp Camp Contribution as soon as possible. This application will be processed once the deposit has been received. When paying by Direct Deposit please use campers name as deposit identifier.
Required
Teen Ranch Individual Waiver & Indemnity Form
Once your submitted camp registration has been received you will be emailed a copy of the Teen Ranch Individual Waiver and Indemnity Form. This needs to be completed and returned prior to Amp Camp. Without this your child will not be able to participate in the activities offered at Amp Camp.

Travel Assistance Request - for Interstate and Rural attendees
Should your travel assistance request be successful, reasonable vehicle and flight costs incurred during travel to camp may be paid by the Amputee Association of Sydney. The travel Coordinator will assist in making necessary arrangements such as airport transfers, accompanied / unaccompanied flights etc. It is our vision to enable youth from all over Australia to attend the 2018 camp. Please contact us if you require any assistance or further information.

Travel Coordinator - Therese Howell P: 0439905533 E: rthowell@netspace.net.au

Required Travel Information
Distance:
Travel Requirements
Return Travel Dates *
Required
Airport Info: Preferred Departure Flight Airport:
Your answer
Airport Info: Preferred Return Flight Airport:
Your answer
Personal Requirements
Please detail any other travel requirements you may have:
Your answer
A copy of your responses will be emailed to the address you provided.
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